Thoracic: Mechanical Circulatory Support
Commentary: Building bridges with extracorporeal membrane oxygenationIn this issue of JTCVS Techniques, Hawkins and colleagues1 present a challenging case of iatrogenic tracheal injury after multiple intubation attempts. The patient had presented with respiratory compromise due to viral pneumonia, and the resultant loss of tidal volume due to the tracheal injury precipitated profound respiratory failure and acidosis. After transfer to the authors' institution, the patient was promptly placed on veno-venous extracorporeal membrane oxygenation (ECMO), which allowed for stabilization and normalization of acid-base status.
Commentary: To bleed or not to bleed, that is the question—Anticoagulation in surgical patients on prolonged extracorporeal membrane oxygenationExtracorporeal membrane oxygenation (ECMO) can tremendously facilitate complex airway surgery or surgery in patients with limited cardiopulmonary reserve.1-3 Hawkins and colleagues4 report a complex case of a 53-year-old female patient with viral pneumonia, an iatrogenic tracheal tear, and severe soft-tissue emphysema. A femoro-femoral venovenous ECMO was established to initially stabilize the patient and support the surgical repair. Subsequently, the ECMO was prolonged for 2 weeks to reduce ventilation pressures and thus facilitate the healing of the airway.
Extracorporeal membrane oxygenation for management of iatrogenic distal tracheal tearTracheobronchial injuries during intubation are rare, with an incidence of 0.005%; thus, diagnosis requires a high index of suspicion.1 Risk factors include female sex, age older than 65 years, and emergency intubation.1,2 Temporal correlation with respiratory failure, subcutaneous emphysema, and pneumothorax/pneumomediastinum should prompt evaluation of the tracheobronchial tree. Bronchoscopy is instrumental for diagnosis and management, including placement of the endotracheal tube distal to the injury before definitive intervention.
Commentary: Veno-venous extracorporeal membrane oxygenation in areas with high coronavirus disease 2019 (COVID-19) burden: Other causes must still be ruled outThe cardiac surgical community's attention has been highly focused, and rightly so, on the coronavirus disease 2019 (COVID-19) pandemic crisis for the past few months. Our extracorporeal membrane oxygenation (ECMO) expertise has been mobilized to address the patients with the most severe forms of respiratory failure secondary to COVID-19.1 The clinical picture of severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) infection is deceptively similar to many other known, and some less well described, causes of acute lung injury (ALI).
Commentary: “Preparedness in the time of COVID”: Implications for engagement of the health care team with acute respiratory failureE-cigarette, or vaping, products have been available for more than 10 years. These devices emit aerosols containing nicotine, flavoring, and often other additives, including tetrahydrocannabinol. They were initially lauded as less-harmful alternatives to inhalational tobacco products, but in 2019 there was a nationwide outbreak of e-cigarette or vaping product use–associated lung injury (EVALI), with more than 2500 hospitalizations and 60 deaths.1 Patients with EVALI may present with tachycardia, tachypnea, hypoxia, leukocytosis, and chest computed tomography findings of bilateral ground-glass opacities.
Extracorporeal support to treat E-cigarette or vaping product use-associated lung injury (EVALI) during the coronavirus disease 2019 (COVID-19) pandemicInformed consent was provided by the patient for this report. The patient was a 30-year-old female with a history of depression, hypothyroidism, intravenous drug abuse, and hepatitis C, G2P0010 at 33 weeks' gestation. She presented to her local hospital with shortness of breath and chest discomfort and plausible contact with verified cases of coronavirus disease 2019 (COVID-19). She required increasing levels of oxygen and was intubated. Computed tomography of the chest ruled out pulmonary embolism but revealed diffuse ground-glass opacities (Figure 1).